REUSABLE ADULT CIRCUIT TUBING
Report
- Report Number
- 9611451-2012-00779
- Event Type
- Malfunction
- Date Received
- November 4, 2012
- Report Date
- October 10, 2012
- Manufacturer
- FISHER & PAYKEL HEALTHCARE LTD
- Product Code
- BZO
- Product Problem
- Yes
- Report Source
- Manufacturer report
- Reporter Location
- NZ
- Reporter Occupation
- OTHER
Narratives
(B)(4). METHOD: ALL FIVE COMPLAINT TUBES WERE RECEIVED FOR EVALUATION, FOUR FROM LOT 111020 AND ONE FROM LOT 110810. THE TUBING WAS VISUALLY INSPECTED FOR DAMAGE. RESULTS: VISUAL INSPECTION OF THE COMPLAINT TUBES REVEALED TEARS IN THE OUTER FILM OF THE TUBING OF FOUR OF THE DEVICES. THE OTHER DEVICE WAS UNDAMAGED AND WITHOUT DEFECT. THIS WAS THE FOURTH COMPLAINT RECEIVED FOR THE 900MR068 TUBING, FOR LOT 111020. CONCLUSION: BASED ON THE FACT THAT THE DAMAGE WAS FOUND PRIOR TO USE, WE HAVE DETERMINED THAT THE DAMAGE WAS THE RESULT OF A MANUFACTURING FAULT THAT WAS NOT PICKED DURING THE VENDOR'S INSPECTION OR WHILE BEING PACKED AT FISHER & PAYKEL HEALTHCARE'S PRODUCTION FACILITY. THE REUSABLE TUBING IS MANUFACTURED BY SMOOTH-BOR PLASTICS IN (B)(6). SAMPLES OF THE COMPLAINT TUBES WERE SENT TO SMOOTH-BOR FOR EVALUATION. SMOOTH-BOR EVALUATED AND TESTED THE DEVICES AND REPORTED THAT THEY COULD NOT IDENTIFY A FAILURE MODE, AS THE TUBES WHEN RECEIVED WERE RUN AT ALMOST NOMINAL FOR ALL PARAMETERS REVIEWED. THEY FURTHER STATED THAT THE MATERIAL USED FOR THE 900MR068 TUBING IS THE MOST STURDY MATERIAL THAT THEY OFFER. WHEN ASKED ABOUT QUALITY CHECKS, THEY TOLD US THAT A PULL TEST IS DONE ON THE LINE BY GRASPING THE TUBE WITH THE HANDS ABOUT HALF A METER APART AND PULLING EVENLY IN OPPOSITE DIRECTIONS. IF THERE IS AN ADHESION//INTERFACE PROBLEM, THE TUBE WILL BREAK ALMOST IMMEDIATELY. THEY ASSURED US THAT THIS IS HOW ADHESION/INTERFACE INTEGRITY HAS BEEN CHECKED FOR 40 YEARS.
A HOSPITAL IN (B)(6) REPORTED THAT FIVE 900MR068 REUSABLE ADULT BREATHING CIRCUITS WERE FOUND TO BE LEAKING AT FIRST USE. THIS WAS FOUND PRIOR TO PATIENT USE.
Devices
| Seq | Brand | Generic | Product Code | Manufacturer | Model | Lot | UDI-DI |
|---|---|---|---|---|---|---|---|
| 1 | REUSABLE ADULT CIRCUIT TUBING | BZO | BZO | FISHER & PAYKEL HEALTHCARE LTD | 900MR068 | 111020 |
Patients
| Seq | Age | Sex | Outcome | Treatment |
|---|---|---|---|---|
| 1 |